Explanation of Benefits (EOB)

A Model of an Explanation of Benefits

A Part D Plan must send an Explanation of Benefits (EOB) to Plan enrollees during months in which enrollees utilize their prescription drug benefits. The EOB must:

List the item(s) or service(s) for which payment was made and the amount of the payment for each item or service.
Include a notice of the enrollee's right to request an itemized statement, appeal/grievance rights, and exceptions process.
Include the cumulative, year-to-date total amount of benefits provided, in relation to:
a. The deductible for the current year.
b. The initial coverage limit for the current year. (If a Plan provides coverage between the initial coverage limit (ICL) and catastrophic coverage threshold (CCT), plans should give the amount the beneficiary must spend before reaching the CCT).
c. Total Out-of-Pocket Expenditure (TrOOP).
Include the cumulative, year-to-date total of incurred costs to the extent practicable.
Include any applicable formulary changes that the Plan is required to provide notice.

NOTE: All year-to-date total amounts mentioned above in (b) and (c) should not include amounts paid by the member's current or former employer/union or another insurance plan or policy.

Date of Service <mm/dd/yyyy>

Name of Drug[*]

Quantity Dispensed

Cost of Prescription

Amount Paid by <Plan Names>

Amount Paid by You

Instructions:

Plans do not need to adhere to the format of this model document. Plans may utilize their own format as long as the EOB contains all model language exactly as provided below.
Notes to plans in the squiggle brackets must not be included in the document.
Plans that offer an enhanced alternative plan must include all the bracketed notes to members discussing non-Medicare Part D drugs.

Part D Model Explanation of Benefits (EOB)

<Member Name>	<Date>
<Street Address>	Member ID Number: <Member ID>
<City, State Zip Code>

Your Medicare Prescription Drug Coverage

This document includes a summary of claims processed from <mm/dd/yyyy> through <mm/dd/yyyy>. It also includes a cumulative statement of the benefits you have been provided this year.

Drug Expenses
[Note : We offer additional coverage on some prescription drugs not normally covered in a Medicare Prescription Drug Plan . The amount paid for these drugs is not included in any of the amounts listed below.]

Annual Deductible

[You have met <insert amount> of your <$xx> deductible for <year>.

[There is no deductible for this plan this year.]

[If you are getting extra help paying for your prescription drugs, you have met <insert amount> of your $50 deductible.]

[If you are getting extra help for your prescription drugs, you do not have a deductible this year.]

Amount Paid For Prescriptions [Between the Deductible and the Initial Coverage Limit]

You and/or others who have paid for your prescriptions have spent <insert amount> in co-payments and/or co-insurance this year. [In addition, this amount also includes any extra help you get for paying for your drugs.] This amount may also include payments made by your current or former employer/union, other insurance plan or policy. This amount counts toward your initial coverage limit.

<Plan Name> has paid <insert amount>. These payments count towards your initial coverage limit.

Together, <insert amount> has been paid by <Plan Name>, you and/or others. This is the total that counts towards your initial coverage limit of <insert plan's initial coverage limit>.

Out-Of-Pocket Payments After You Reach the Initial Coverage Limit

You have spent <insert amount> since reaching your initial coverage limit. You still have to spend <insert amount> before you qualify for Catastrophic Coverage. {Plans may remove this bullet for members receiving the subsidy.}

Total Out-Of-Pocket Expenditures That Count Towards the Catastrophic Coverage Threshold {Plans: This is the TrOOP balance.}

You and/or others on your behalf have spent a total of <insert amount> on prescription drugs covered by <Plan Name> for <year>. This total includes the amounts spent for your deductible, co-payments and co-insurance, and coverage gap payments. [This amount also includes any extra help you get for paying for your drugs. However,] This amount does not include payments made by your current or former employer/union, another insurance plan or policy, or other excluded parties.

Total Amount Paid For Your Drugs This Year { Plans: This is Gross Drug Spend}

<Insert Amount>. This is the total amount that has been spent on your drugs this year. It includes the amount paid by you and/or others on your behalf towards the initial coverage limit, coverage gap payments and catastrophic coverage. It also includes the amount <Plan Name> paid for drugs during your initial coverage limit and catastrophic coverage.

For More Information
For more detailed information about your <Plan Name> prescription drug coverage, please review your Evidence of Coverage and other Plan materials.

If <Plan Name> ever denies coverage for your prescription drugs, we will explain our decision to you. You always have the right to appeal and ask us to review the claim that was denied. In addition, if your physician prescribes a drug that is not on our formulary, is not a preferred drug, or is subject to additional utilization requirements you may ask us to make a coverage exception.

If you have any questions about <Plan Name>, please contact customer service at <toll-free number>, <days and hours of operation>. TTY/TDD users should call <toll-free TTY number>. Or, visit <Web site> on the Web. If you suspect fraud, please contact your plan or 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048.

THIS IS NOT A BILL. Keep this notice for your records.

Explanation of Benefits
For period beginning <mm/dd/yyyy> and ending <mm/dd/yyyy>

[* Denotes a drug that is covered under an enhanced alternative plan and is not generally covered in a Medicare Prescription Drug Plan. Any payments paid for these drugs do not help you move through the benefit or qualify for catastrophic coverage.) {Plans: payments made by sources other than the member (and/or others on their behalf) or the plan should be notated in the notes column}

Upcoming Changes to <Plan Name>'s Formulary {Plans: this is the 60 day notice chart}
<Plan Name> may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug [and/or move a drug to a higher cost-sharing tier], we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market we will immediately remove the drug from our formulary.

The table below outlines upcoming changes to our formulary that will impact you:

Name of Affected Drug	Description of Change {e.g. removal of drug from fomulary, or changing its preferred or tiered cost-sharing statuts}	Reason for Change	Alternative Drug*	Alternative Drug Co-payment/Coinsurance

*Alternative drugs are drugs in the same therapeutic category/class or cost-sharing tier as the affected drug. Only your physician can determine if the alternate listed here is appropriate for you given the individualized nature of drug therapy. Please consult with your physician as to whether this is an appropriate drug for you.